The Director Regulatory Audits & Investigations will direct and coordinate internal and external auditing and monitoring activities to ensure regulatory compliance for Health Alliance Plan and its subsidiaries, including HAP Empowered, Alliance Health and Life Insurance Company; HAP Preferred, Inc. and Midwest Health Plan (jointly referred to as “HAP”). You will be directing and coordinating investigations of compliance reports, including reports of fraud, waste or abuse and general non-compliance within the health care insurance company of a large integrated health system. The Director will oversee and conduct audits and investigations of business areas and first tier, downstream and related entities (FDRs) and delegated entities (DEs), analyzes audit and investigation findings, makes recommendations for remediation, based on findings to ensure corporate compliance with federal and state regulatory requirements. Develops and implement reports and dashboards to communicate findings to leadership. Completes risk assessments, develops and implements annual auditing plan and Corrective Action Plans (CAPs).

PRINCIPAL DUTIES AND RESPONSIBILITIES:

• Direct the management of audits and investigations of business and FDRs/DEs practices to ensure compliance with government program standards and regulations, including but not limited to, Medicare Advantage, Medicaid, ACA and FEHB regulations
• Report audit and investigation findings, the impacts to the organization, and provide unbiased, objective recommendations to management and the Chief Compliance Officer
• Develop and implement annual auditing and monitoring plans as well as data mining efforts for investigations, to pre-emptively uncover issues of non-compliance and Fraud, Waste and Abuse within the business areas, and address issues to ensure compliant practices up to and including CAPs.
• Implement continuous improvement strategies supported by standards and procedures for internal regulatory auditing and investigating.
• Provide support to risk assessments by directing and prioritizing the annual audit plan, allocating appropriate resources and attention to high risk areas.
• Lead the reporting of findings to provide recommendations to leadership for policy, process and system changes to address root causes of non-compliance and reduce organizational and regulatory risks.

• Maintain up-to-date knowledge of all government programs standards and regulations, including but not limited to, Medicare Advantage, Medicaid, ACA and FEHB regulations.
• Spearhead data mining and investigation assessments to direct and prioritize investigations across all product lines as regulatorily required, devoting resources and attention appropriately to the areas deemed to have a higher risk of non-compliance.
• Develop and oversee a team of compliance auditors and investigators to routinely carry out annual audits, investigation plans and accomplish job responsibilities.
• Under the direction of the Chief Compliance Officer, coordinate resources to ensure the ongoing effectiveness of the compliance program.
• Perform other related duties as assigned.